With the holiday season upon us yet again, I cannot help but find myself swept up in mood to reminisce about this year. 2017 now draws to a close, and brings with it a familiar paradoxical feeling — a first impression suggests that the year passed far too soon, yet, as with every year in my life thus far, a more thoughtful reflection begs me to recall the momentous events that proudly made up another chapter in my life. I am extremely grateful to say that I have been able to advance my life in a manner that has left me feeling accomplished year after year, and I can only hope that my adventures never cease to dwindle in their perpetuity.

Along with many other irreplaceable moments, 2017 brought with it the start of my nursing career. While this alone was no small feat, my transition into the workplace signaled an end to years of tumultuous schoolwork; after studying the science behind health care for so long, I was finally going to put my knowledge to practical use. For newly graduated nursing students however, their first jobs typically assign them to the slowest and most undesirable shifts. To be completely honest, I was not thrilled at the prospect of beginning my career on a “medical-surgical” floor, the sort of unit most new grads end up on since there is little critical thinking expected from the nurses; these nurses are assigned four to seven patients each and are only really expected to pass out medications on time, help patients to the restroom, and bring them snacks when they are hungry. Now I do not look down on such responsibilities and would still happily take care of patients in this way, but as someone who now holds two bachelor’s degrees, I have a far deeper understanding of the biological sciences than some of my nursing school peers. Even so, this was the field I wanted to enter and I would still be happy to take care of patients in this manner. Determined to make the best of my first job (whatever it may be), I made a mental note to try and transfer from the medical-surgical ward to an ICU position after gaining meaningful experience as a nurse.

Ah yes, the ICU. If you ask almost any nursing student, their ideal job would be to work in an ICU. There are many reasons for this — some cite the fact that they want ICU experience so that they can one day apply to become a nurse anesthetist (the salaries of whom easily find themselves in the six figures). Some enjoy the fact that critical care nurses take care of two patients at a time (or, at the very most, three). Some simply like the fact that ICU nursing is the absolute highest tier of nursing attainable without going back to school for a master’s-level education. Whatever the reasoning may be, the esteem of critical care nursing essentially boils down to the fact that such individuals are respected members of the treatment team. Rather than simply acting as odd hybrids between room service and pill dispensers, ICU nurses enjoy a high level of autonomy that lets them actually use the concepts studied in nursing school to care for those clinging to their final moments on Earth and sometimes quite literally save their lives. They have a reputation of knowing what they are talking about, and the on-board ICU medical team (critical care units do not bother with paging doctors constantly since they house their own) treats their concerns seriously since they respect their opinions. These nurses are paragons of their profession.

For this reason, ICU nursing positions are saturated and hard to come by. As I finished up my clinical rotations in nursing school, a number of my preceptors — experienced nurses — were continually attempting to transfer to critical care. Even hiring internally, there were only so many spots to go around. Some who were absolutely desperate for ICU experience were seeking jobs at smaller community hospitals despite the fact that they lacked the resources to deal with the truly critically ill and found their ICUs acting more akin to IMUs (intermediate units) with slightly higher acuity. For new nursing school graduates such as myself, some hospitals had flat-out stopped hiring new grads into the ICU since they had an abundant pool of internal applicants that would require less training.

Still, as a skill-based profession, I could understand the importance of experience when vying for more coveted positions. Thus, having resigned myself to working what would likely entail a medical-surgical position during the night shift, imagine my surprise when I received an offer to start my career in the Surgical ICU, during the day shift, at a major urban hospital situated in nothing less than the largest medical center on the planet. This was not a small, quiet hospital in the suburbs — this was a world-renowned hospital that saw the most complex and puzzling medical cases. This was where the rest of the country flew its patients when all else failed. This was the dream job of many experienced nurses and, for a new grad, nothing short of an absolute fantasy.

I could not have been happier, and I knew that joining the ranks of such elite nurses would bring with it a steep learning curve. It did not take long after I accepted the position for me to receive an invitation from my unit manager to tour the unit.

As the rest of the staff wore scrubs as part of their uniforms, I remember feeling somewhat out of place stepping out of the elevator clad in my business casual attire. I surely must have stood out as I hesitantly approached the nurse station for someone who could direct me towards the unit manager and I was quickly approached by the unit’s patient care assistant who helpfully guided me accordingly. Slightly nervous at the prospect of meeting my manager in person, I was pleasantly surprised to be greeted by a warm, welcoming woman who enthusiastically showed me around the unit. As she walked me through the cozy 12-bed ICU, I found myself taken aback by the enormous windows offering a majestic view of the sunrise across the medical center. Thinking back to my nursing school rotation at a neighboring hospital where the sullen basement-level cardiovascular ICU housed rows upon rows of patient beds separated by mere curtains, I somewhat reflexively (and quite typically) felt the words escape from my mouth, “wow… this place isn’t depressing at all!”

She knew I was not being sarcastic, but my manager certainly gave me a quizzical look and hesitantly asked, “were… you expecting it to be?” With a laugh, I proceeded to discuss my only other experience with critical care during nursing school. As the tour concluded, she confided in me her enthusiasm for my presence yet again — apparently, this ICU only hires one new grad every few years. Given their general unfamiliarity with newly graduated nurses (as opposed to internally transferring experienced nurses), I was soon about to become a spectacle for the unit — whether this was a good thing or a bad thing was yet to be determined.

My orientation period would last around four months — about a month longer than the training given to a new grad starting on a medical-surgical floor and about three months longer than that given to an experienced nurse joining the ICU. For many, orienting to their first nursing job proves to be the most difficult phase of their career since they have not yet developed their nursing skill-set. Depending on the type of preceptor they are paired with, such a precarious period of learning can be supplemented with support, sympathy, frustration, exasperation, or helplessness; a preceptor has the power to make or break an orientee’s spirit with regards to their place on the unit.

As I stepped into the Surgical ICU on my first day however, I knew the type of unit I was getting into.

Spread across the nurse station was a large banner welcoming me to the unit, and I was formally introduced to the entirety of my coworkers who were present for our monthly team meeting scheduled that day. I was acquainted with Anna, the nurse who would serve as my preceptor for the next few months, and had my photo taken to join the rest of the staff on the unit bulletin board advertising the “A-Team.” I was official now!

I quickly found out what an incredibly earnest instructor I had been paired with. At almost every opportunity, Anna went the extra mile to make sure that I felt comfortable on the unit (she would constantly introduce me to new faces), understood the routines expected of me (she would go home and print out helpful tip sheets for me to follow), and even made it a point to strategically expose me to key hospital committees such as the Staff Nurse Professional Practice Council (a plan that actually worked and directly led to me getting accepted to the institution’s Nursing Research Council). She was someone who piped up to share the blame whenever I would make a mistake and vouch for me whenever a patient felt uncomfortable being taken care of by the “new nurse.” She would intentionally pair me up with some of the sickest patients so that I could feel prepared when I came off orientation and, despite not being present on the unit that day, made it a point to text me during her birthday for the sole purpose of making sure that my backup preceptor was being kind to me. Anna was a preceptor that genuinely cared — not just about me, but also for the profession that she was role modeling.

Thanks to Anna’s efforts, it did not take long for me to start mingling with the other nurses on the unit, all of whom were happy to help me out. Since I was the first new grad nurse that had oriented to the unit in a while, I quickly became the “baby” of the unit; practically every member of the staff enjoyed acclimating me to the world of nursing and very tenderly spent time answering my novice questions to set me up for success rather than failure. Everyone made me feel like a part of the team, and it was not uncommon for them to repeatedly come check up on me during my day.

This support was not limited to the nursing staff. As an ICU, our unit has an in-house team of nurse practitioners and physicians. One of our nurse practitioners, Lauren, has a constant chipper personality (to the point that some poke fun at her for it) and would frequently go out of her way to interject her praise during my orientation. For example, there was a phase on the unit where it was well-known that I was learning to delegate tasks to other nurses (a surprisingly delicate skill) and I asked a coworker, AJ, to replace the pulse oximeter on one of my patients within earshot of Lauren. In an absolutely livid tone, Lauren immediately questioned me, “DID YOU JUST TELL AJ TO REPLACE THE PULSE-OX ON YOUR PATIENT?!” I tentatively answered to the affirmative, and Lauren immediately smiled, calmly replying, “Nicely done!!” while another coworker clapped gently. The other nurse practitioners would also sit down with me to share the tricks they had gleaned with years of experience and on more than one occasion, they bought lunch (from delicious eateries like Jimmy John’s!) for the entire nursing staff. This was the sort of atmosphere I was a part of.

Needless to say, I was having an incredible time on my unit while adjusting to my life as a nurse. Alongside all this however, the new grad orientation period at my hospital also necessitated “classroom days” in addition to our shifts on the unit. Our classes included various exams that we had to pass (under penalty of unemployment, as we had seen first-hand with some of our former peers), important lectures about hospital policies, and mandatory assignments by our nurse educator. While I was enjoying my time on the unit, I have to admit that old habits die hard and I was the sort of student who would cause grief for their teacher (a middle aged woman with a prying stare who I would liken to a witch). This instructor actually replaced our former teacher in the middle of our orientation and was comparatively a nuisance in the way that she would constantly hover over us to ensure that we were working; our old teacher let us work at our own pace and treated us like adults. Unsurprisingly to some, this led to some friction between her teaching style and my learning style with a particularly memorable moment culminating in a confrontation as to why I had not completed any of my assignment modules (to which I responded that she had not given us a due date). In this particular instance, I eventually did decide to work on my assignments and had to ask my classmate Mallory in a hushed whisper how to log into the software, which left Zach, my peer sitting adjacent to her, in stitches since this indicated that I had never once even attempted to do my assignments until now. Even so, the look on the teacher’s face was priceless on the day of the final exam, which can most succinctly be summed up in her peeved exclamation:

“You come in late, finish first, then get the highest grade in the class?!”

Still, classroom days never amounted to much more than distractions from life on the unit. I much preferred spending time with my coworkers and learning my trade, though there were certainly ups and downs. Some days I ended triumphant — confident that I had provided excellent care to my patients. On other days, I felt defeated to the point that I did not want to reflect on my performance with Anna, instead opting to seek the wisdom of another. There is one such day that I recall where I ran into one of our travel nurses, Christina, in the parking garage.

To imagine what Christina is like, well… suffice it to say that upon meeting her, Anna turned to me and said, “…you can tell that she’s not from around here.” See, Christina was an experienced ICU nurse from the Bronx borough in New York City — a rough neighborhood where only the toughest, no-nonsense nurses could survive amidst the constant parade of violently injured patients being brought in. There was not a trace of white-bread Midwestern dialect in her speech. She was also someone who could always find kindness within herself to share with her coworkers. Noticing that I looked drained after the day’s shift, she dived into a passionate pep talk of her own accord. She ranted to me about a personal anecdote that honestly did not have much to do with anything, but eventually got around to summing up her point: she has been a nurse for seven years and has never once had a shift where everything felt perfect afterwards.

Small moments like my encounter with Christina usually left me feeling encouraged, and always made me feel a part of the team. Once again, the entire unit could be counted on to take care of me and I could literally go to anyone (even the patient care assistants, physical therapists, and pharmacists!) for advice whenever the going got tough.

This of course included Anna. As my mentor, her support was implicit and I never doubted it, but in order to truly serve as my teacher and prepare me for the rigors of critical care nursing, she also had to be somewhat rough on me during training. I distinctly recall that the last few weeks of my orientation period had me caring for some of the sickest patients on the unit — the sort who may not even make it through the night. On my first such shift, I was absolutely clobbered and needed a lot of help in keeping track of everything that had to be done to keep the man alive. As the days wore on however, I found myself slowly growing more comfortable with the tasks expected of me and soon began to better anticipate where to direct the majority of my attention amidst the volatile condition of the patient. I was quite surprised at the fact that I could feel the improvement.

I must also note that Anna’s training employed some rather devious methods as well! There was a memorable instance where a coworker, Audrey, went up to her for assistance in another room. At the time, Anna was teaching me how to balance the time spent on my own tasks with the time one should allot to help their coworkers (a distinction that is surprisingly difficult to demarcate when not experienced in the field). After a brief chat with Anna, Audrey ended up coming into my room, stating that Anna wanted to be treated as if she were not present on the unit. She then, almost in a sing-song voice, proceeded to ask my favor, “sooooo, are you busy? I neeeeed your help because I’m taking care of [a well-known needy patient] next door!” I distinctly recall giving her a long pause before finally relenting, which prompted a strange facial expression from her that looked like… excitement? I then heard, from across the unit, Anna’s voice. “Did [Nightmaren] just say yes?! [Nightmaren]! NO! YOU’RE BUSY RIGHT NOW!”

Audrey just sort of trotted away while chuckling to herself — I had been trapped! Humorous as the encounter had been however, I must say that this lesson is one that has stuck with me since my training and has directly improved my prioritization while working as a nurse; Anna taught me to finish what I was doing before helping others, a far cry from a nursing student’s near sycophantic willingness to help during clinicals. If I ever get the chance to train my own fledgling nurse, I might have to use this same trick!

These were all minor lessons however; they were intended to refine me into not simply a competent nurse, but an exceptional nurse. It was not long until I was ready to fly solo and when I completed my final orientation shift with Anna, she could not have been happier. I was amused to later find out that Anna would regularly brag to the rest of the team about how well I was progressing with my training and rave about how how knowledgeable I was about pathological processes. Naturally not a word of this praise was shared with me during orientation, but a part of me had to smile at how earnestly Anna kept up her role as the stoic, wizened teacher who was secretly proud of her student. After one particular instance of caring for the same patient that I had taken care of the day prior, I found a text from Anna waiting for me:

“[Nightmaren] I didn’t tell you this yesterday bc I was pulled to another unit but you did SUCH a great job. [You’ve] stayed on top of life and really are doing a great job of keeping up. I took care of bed 5 after his liver transplant today and the family was raving about you and how organized you are and how neatly you take care of their son. My heart almost burst with pride! You are doing really well!”

Despite the fanfare, I must say that finally working on my own felt decidedly… normal. There was no Earth-shattering feeling of freedom just as there was no perception of abandonment. Thanks to Anna’s efforts, flying solo felt completely natural.

I had the opportunity to relay this impression with my manager when I unexpectedly ran into her in the corridor one day as I was headed home. I truly had a lot to be thankful to her for — it was she who had fostered such a positive culture on the unit and, accordingly, had been supportive of my progression through orientation since day one. She was of course happy to hear my compliments, noting that I had been adapting well and that I will soon start to “glide,” but then, to my surprise, she thanked me. “Thank you for joining the team,” she said. I was momentarily taken aback — she was thanking me? Any nurse hired in my position would be immensely grateful for the opportunity, yet my manager was thanking me as if I were the one who had done her a favor. Such was the culture on our unit.

These days, well, life is not too different from the way it was a few months ago. Sure I am off orientation, but the rest of the unit still goes out of their way to check up on me quite frequently… just in case. I actually worked both on December 24th and the 25th so I got to spend Christmas with these guys, which was quite fun — everyone brought snacks and drinks so there was plenty to stuff ourselves with while we did what we love. Now that I am off orientation, all I need to worry about is continuing to gain experience so that I can become the best nurse possible in my field.

So why do I feel that it was just yesterday when I clambered into the elevator to enter my graduate nurse classroom for the first time?

Any nurse could tell you. I still have a lot to learn.

In fact, it is one of the main things that drew me to nursing. Nursing is a lifelong journey of growth — it not only demands constant, evolving education, but also a capacity for creativity that, in some days, makes one’s work feel more akin to that of an engineer. There is no replacement for a seasoned nurse’s experience and, while I can be depended upon to safely go about my tasks during a shift, there are a lot of little tricks that I can only learn by interacting with different patients over time. In a strange way, it reminds me a bit of my first Playstation 2 game, Sly Cooper and the Thievius Raccoonus. After recovering all of the lost pages of the “Thievius Raccoonus,” a tome of thievery techniques passed down across generations of the Cooper family line, there is a poignant cut scene in which the titular character, Sly, is shown lovingly piecing the book together before finally turning to a blank page to start chronicling his own journeys. The time has now come for me to do the same — I have been molded from the experience of my teachers, and my teachers’ teachers. As I figure out my own rhythm and my own tricks to tackle the unique problems that seem to crop up in critical care situations, I know in my heart that I too will one day be passing these down to a successor.

One Comment

I remember how excited I was when I heard of your opportunity to work at such a wonderful hospital. Not only that, but to start right at one of possibly the most coveted and well respected position, the ICU!

I don’t think there was ever a doubt in my mind on how well you’d be able to adapt in such a volatile environment. You’ve always been talented with acclimating yourself in any situation. Honestly, it really is no surprise many of the already existing staff of the ICU are impressed with your work.

What’s equally impressive is how well Anna was able to train you. There’s something to be said when an trainer/mentor not only can teach their pupils well, but also make an impression that will last. Really, I’ve a lot of respect for her and her methods of teaching. I would find it a huge honor if I were ever to have the privilege of meeting her.

Honestly, this whole journey of yours is perhaps one of the most interesting and humorous ones I have ever encountered. What’s even more fascinating is just how much had changed in four years. 2014 was the year of “self-destruction”, 2015 was the year of “self-repair”, 2016 the year of “moving forward”, and finally 2017 was the year this saga had concluded only to start a new one.

Indeed, this new nursing saga proved to not only continue what one would expect from your antics, but it also really set in stone that this was, in fact, a new chapter in your life. One I’m sure several of us had wondered what it would be like. It is reassuring, to say the least, that it still maintains that atmosphere one, such as I, has become familiar with as I got to know you.

Speaking of which, I found the working environment you’re currently in to be such an insightful one in a strange way. Not only did it oddly reflect just the kind of work ethic you’d employ, but also the kind of attitude I think is the most appropriate for such an important unit. The fact that your manager thanked YOU for being part of the team shows just how much they value each person in their unit and how incredibly important they feel it is for one to feel a part of the group.

I always did say it’d be interesting to see how work life would be for you. So far, it appears I was right on the dot.

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Kept After Class is a blog for Nightmaren, a student who just doesn't have enough free time anymore. This journal strives to remember the author's most treasured experiences— Time stops for no one; one never knows how much they have until it no longer exists.